Localizing intramyocardially embedded left anterior descending artery during coronary bypass surgery: literature review
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REVIEW
Open Access
Localizing intramyocardially embedded left anterior descending artery during coronary bypass surgery: literature review Edem Ziadinov* and Hilal Al-Sabti
Abstract Proper detection of the deeply embedded left anterior descending artery remains a challenge. Many authors proposed different methods for artery identification, such as ultrasound Doppler, cineangiography, retrograde dissection overlying tissues, and exposure over the probe. Choice of the technique often depends on the surgeon's acquaintance and experience. The article compares and summarizes different procedures for the detection of intramyocardially located left anterior descending artery. Keywords: Coronary artery bypass grafting, Embedded coronary artery
Review Introduction
The left anterior descending (LAD) coronary artery is the most important artery for coronary revascularization procedures. It is predominantly grafted by left internal mammary artery, what is considered as a “gold standard” of coronary bypass surgery. It usually has a surface course and may be easily identified. However, in some cases, the artery passes intramyocardially, or acquires a moderate layer of fat, what makes it difficult for detection. In a study of seventy patients undergoing coronary artery bypass grafting (CABG), intramyocardial coronary arteries occurred in 17.7%. The most common intramyocardial part (58.6%) represents on the border of proximal and middle portions of the coronary artery [1]. The standard and informative method for cardiac arteriolar system investigation is coronary angiography. Meticulous examination of the angiographic data, especially oblique views, is essential for preoperative identification embedded LAD. The intramyocardial part of the LAD usually dives at an acute angle into the myocardium and appears straight, unlike the serpentine course of the surface vessels (Figure 1) [2,3]. In some cases, a small portion of the artery comes up to the surface, which may be
* Correspondence: [email protected] Department of Surgery, Cardiothoracic Surgery Division, Sultan Qaboos University Hospital, Al Khoud, Muscat, Sultanate of Oman
grafted, or may be a reference to locate other place on the artery for further grafting. Intraoperative investigation of the outer surface of the heart and definition of the main landmarks, arterial and venous branches is the clue to less traumatic determination LAD. It is important to remember that the intramyocardial LAD is usually to the right of the great cardiac vein [2]. Sometimes LAD may be found beneath the small but visible groove on the surface of the heart. That happens because artery embriogenically has underdeveloped connections with the epicardium. When fat accumulates subepicardially, the LAD often pulls the epicardium forming a groove. In patients with angiographic evidence of an intramyocardial LAD, the course of the vessel should be investigated before aorta cross-clamped [2]. A self-retaining eyelid retractor is a simple, readily available and useful tool for searching embedded vessel.
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